Healthcare Provider Details

I. General information

NPI: 1982510517
Provider Name (Legal Business Name): LATITUDE 41 MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 N MAIN ST UNIT 7A
KENT CT
06757-1551
US

IV. Provider business mailing address

PO BOX 98
KENT CT
06757-0098
US

V. Phone/Fax

Practice location:
  • Phone: 312-890-9331
  • Fax:
Mailing address:
  • Phone: 312-890-9331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE TOLBERT
Title or Position: APRN PROVIDER / OWNER
Credential: APRN FNP BC
Phone: 312-890-9331